PROJECT SUMMARY Background: Cancer screening can lower cancer-related mortality and morbidity but may be associated with significant harms and burdens in older adults. There is often a lag-time of 10 years before patients screened for breast, colorectal, or prostate cancers actually benefit. On the other hand, multiple harms from screening can occur in the short-term. Older adults with limited life expectancy continue to receive cancer screening at high rates even though it exposes them to the harms of screening with little chance of benefit. Clinicians are a major driver of over-screening but why they often continue to recommend cancer screening in older adults with limited life expectancy is unknown. This proposal aims to improve the cancer screening of older adults by 1) identifying the factors that facilitate or hinder clinician recommendations to stop routine screening in older adults with limited life expectancy, and 2) better supporting clinicians to appropriately incorporate life expectancy in their screening recommendations. Research proposal: Aim 1 will use qualitative methods to understand the range of factors that facilitate or hinder clinicians from recommending screening cessation in older adults with limited life expectancy. Aim 2 will test these factors in a national physician survey to determine and quantify their effects on physicians' screening recommendations in older adults with limited life expectancy. Aim 3 will then develop and pilot test a novel multi-modal intervention to target the factors that significantly contribute to over-screening. The intervention will be developed with input from clinicians and older adults and will use multiple, overlapping strategies that may include decision support, communication coaching, and clinician feedback. Career development plan: The candidate is a geriatrician who has already demonstrated national and institutional leadership in research and a strong track record of academic scholarship with numerous high impact publications and early investigator grants. Her long-term career goal is to be a research leader focused on incorporating life expectancy to inform patient-centered, individualized preventive care decisions for older adults. She has laid out a comprehensive, feasible career development plan that will enable her to transition into an independent investigator and research leader. She proposes to learn new skills in decision support, clinical trial design, and implementation science, in addition to continued development of leadership skills. She has assembled an exemplary mentoring team with expertise in the subject area and the relevant research methods and works in a rich research environment with tremendous resources to support her development. Summary: The proposal addresses an important research gap and produces a novel intervention that may have major impact to improve the cancer screening of older adults. The results from this proposal will support a subsequent large-scale clinical trial to test the intervention. This proposal will also further foster the career development of the candidate into a research leader focused on individualized preventive care in older adults.